Upheld, recommendations

Summary

C complained about the decision by their housing association to issue them with a final warning in respect of their tenancy following a decision by the police to charge C with two offences in respect of alleged anti-social behaviour. In particular, C stated that the housing association had failed to follow their own anti-social behaviour policy when issuing the warning in that they had not offered C the opportunity to discuss the incidents prior to the final warning being issued.

The housing association stated that the decision to issue C with a final warning had been made on the basis that C had breached the terms of their tenancy agreement and was already well aware of the likely consequences for their tenancy if they continued to behave in what the housing association considered to be an anti-social manner following a previous meeting to discuss a separate incident. The housing association also advised that C could not have been invited into the housing association's offices to discuss the incidents giving rise to the police charges prior to issuing the final warning due to the coronavirus restrictions in place at the time.

We found that the housing association had failed to follow their policy on antisocial behaviour by proceeding to issue a final warning to C in respect of their tenancy without firstly having offered C the opportunity to discuss the incidents resulting in the police charges. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the association's failure to follow its anti-social behaviour policy prior to issuing them with a final warning in respect of their tenancy. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Offer C the opportunity to discuss the issue and then, based on any matters discussed, review the decision to issue a final warning in respect of their tenancy.

What we said should change to put things right in future:

• Staff should act in line with the association's anti-social behaviour policy.

Summary

C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in their home was poor; that there was a delay in transporting A to the hospital; that C was asked to commence cardiopulmonary resuscitation (CPR) on A whilst on route to hospital and that C was not assisted by the ambulance technician and that they alone performed CPR on A until they arrived at hospital.

C was dissatisfied with the way in which their complaint was investigated. It was initially investigated by the SAS, however, when contacted by SPSO, SAS requested to reinvestigate the complaint in light of an error that they identified in their initial response. C remained unhappy after receiving the SAS's further response and asked us to consider the matter.

We took independent advice from an emergency and retrieval medicine adviser. We found that the way in which the dispatch of the ambulance was handled was unreasonable, that the initial care provided to A in their home was reasonable, nevertheless it should have been clear to the ambulance crew that A was seriously unwell and that the time spent on scene was unreasonable and that the decision to ask C to perform CPR in the ambulance was not reasonable.

We found that the initial investigation was not sufficient, although we acknowledged the proactive steps taken by SAS to address this issue and acknowledge failings, including asking C to commence CPR. We also found that in this case the full crew should have been interviewed. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified that have not already been acknowledged in previous responses including the length of time taken to assess A in their home and the delay in transporting A to hospital, the failure to follow clinical guidelines appropriately and the failure to handle C's complaint appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Complaint investigations should be thorough and accurate in the first instance.
• For patients suffering cardiac arrest out of hospital such as in this case, relevant clinical guidelines should be followed by ambulance crew. Ambulance crew should accurately record what treatment was performed to demonstrate adherence to the clinical guidelines.
• When it is clear from initial assessment that a patient is seriously unwell, their transfer to hospital should be expedited and delays should be avoided.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the board's decision to discontinue the prescription for gluten free foods for their adult child (A). The board explained that as A did not have a confirmed diagnosis of coeliac disease, that they would not be expected to prescribe gluten free foods. To make a diagnosis, a patient would be required to include gluten in their diet for a number of weeks prior to testing. C said that due to A's additional needs and the distress that they would suffer from the symptoms associated with taking gluten, it would be reasonable for the board to take a flexible approach when applying their policy on the matter.

We took independent advice from both a GP adviser and a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). It was noted that it was agreed by all parties that it would be distressing to A to require them to include gluten in their diet in preparation for testing. We considered that a more flexible approach should be taken to the application of the relevant policies and guidance and that a diagnosis could be made by probability. We found that principles of realistic medicine and patient-centred care should be applied and we recommended that consideration is given to other means of non-invasive tests to determine the presence or absence of coeliac disease in A's case. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should explore and discuss with C other means of non-invasive testing to determine the presence or absence of coeliac disease in A's case.

Summary

C made a complaint about the nursing care and treatment that their late parent (A) received at University Hospital Wishaw. C was concerned that A was not nursed in an elevated position and was kept lying flat. C also said that A's nutrition was not taken seriously and that the food record charts were not completed properly to monitor A's intake.

We took independent advice from a nursing adviser. We found that it is not usual to document a patient's position in bed (whether they are upright or lying flat). Therefore, we were not critical of the board's record-keeping in this regard. We found that the monitoring of A's nutrition and fluid intake was unreasonable because the Malnutrition Universal Screening Tool (MUST) assessment was not completed within 24 hours of A's admission to hospital, the food record chart and the fluid balance chart were not completed appropriately during A's admission and A's personal centred care plan was not updated to reflect their condition. We upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not completing the MUST within 24 hours of A's admission, not appropriately completing the food record chart and fluid balance charts during A's admission and not updating A's person centred care plan to reflect their condition. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patient intake of fluid should be accurately and timeously recorded.
• Person-centred care plans should be reviewed and, where necessary, updated to reflect the needs of the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their parent (A) received during an admission to a community hospital.

A had a degenerative condition which affected their mobility and was latterly diagnosed with a form of vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain). A was admitted to hospital following a fall. C told us that A had a number of falls in hospital and suggested that one of these falls led to an injury to A's leg. C raised a number of general concerns regarding the nursing care and implied that A was allowed to become dehydrated, only drinking when assisted by family members or when family members prompted the ward staff.

C also raised concerns about the clinical aspects of A's care. C said that A became lethargic and unresponsive during their admission to hospital. Family members expressed their concern to staff that this may have been the result of sepsis (blood infection) or a urinary tract infection. However, they were reassured that A's symptoms were likely caused by antibiotics.

A suffered a heart attack. Staff performed cardiopulmonary resuscitation (CPR) and revived A. A was then transferred to a general hospital for care where A died five days later. C explained that A was uncomfortable and agitated during their final days. C said that staff there had expressed concern that no Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) had been signed for A. C complained that the additional five days of suffering that A experienced could have been avoided had a DNACPR been discussed with family members.

We found that A's condition and medical history meant that clinical staff should have considered DNACPR each time that they reviewed A. Whilst we were critical of the board for failing to do so in A's case, we acknowledged that they had already taken action to improve their procedures and ensure that the consideration of DNACPR is not left until an emergency situation develops.

We found that A had developed sepsis, likely as a result of the leg injury sustained during their admission. We noted an apparent delay of several days before the cut to A's leg was identified. However, once the nursing staff were aware of this, they appropriately escalated the situation to the clinical team. We found that no clinical review was carried out and that the nursing staff instead consulted NHS24 for advice as to how to treat A's leg. A was treated with oral antibiotics. We found that had A been reviewed in person by a member of the clinical team, the severity of their infection may have been recognised and intravenous (into a vein) antibiotics may have been prescribed. We noted an overall lack of clinical input into A's care during their admission and concluded that this led to a failure to diagnose A's sepsis.

With regard to the nursing care that A received, we found that there was a four day delay to A's falls risk being assessed and mitigated after their transfer to hospital. The number of falls A had and the severity of the harm caused increased during this time and we found that this was a clear failure to adapt to a patient's specific needs. We were critical of the board for failing to record and monitor A's leg wound in a wound chart.

Whilst we were satisfied that there was evidence of the nursing staff monitoring A's food and fluid intake, we noted that their focus was on the weekly variations in A's weight. This meant that A's significant weight loss over a longer period was not identified. Had it been, staff may have taken proactive steps to increase A's intake and increase their weight. We upheld all aspects of this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the board conduct a review of the nursing care provided on A's ward and take steps to ensure that they are compliant with the relevant standards for falls risk assessment, nutritional assessment and wound care.
• The board conduct a review of the medical provision available to patients on dementia wards at the hospital and take steps to ensure that they meet the standards of inpatient care set out in the guidance from the Royal College of Psychiatrists.
• The board share this decision with the nursing staff.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the board after suffering wound care complications following a caesarean section (an operation to deliver a baby. It involves cutting the front of the abdomen and womb) during the birth of their child. They considered that a number of factors meant that the board had failed to provide reasonable treatment in relation to the birth of their child.

We took independent advice from a consultant obstetrician (specialist of pregnancy, childbirth etc) and gynaecologist (specialist of the female genital tract and its disorders). We found that the board had failed to provide reasonable treatment. In particular, we found that the board failed to follow up on a phone call to ensure C's safety when a full triage could not be completed; that they had failed to ensure a timely review by a senior doctor when complications occurred; that they failed to keep reasonable records of C's care; that they failed to identify that a Significant Adverse Event Review (SAER) should have been carried out, meaning that the staff in question were unable to clearly recollect events by the time the complaints investigation was completed and additionally, that the board made insufficient attempts to establish a cause for the complication, which may possibly have been operator error or the result of faulty sutures, either of which would have required further action to ensure wider patient safety and avoid a repeat. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable treatment relating to the birth of their child. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All relevant staff should know when to suspect complications in post-caesarean wound care and escalate for review by a senior doctor as soon as possible, if indicated.
• If a triage is unable to be completed for any reason, the board should have robust procedures to ensure the safety of the patient in question.
• Sufficiently detailed records should be made of all operations carried out.
• When a wound has ruptured following surgery, the board should ensure reasonable steps are taken to invsetigate the cause of this.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late spouse (A) by the practice. A died due to invasive bladder cancer and urinary sepsis (blood infection). C complained that the practice unreasonably delayed referring A to secondary care for investigation despite presenting with recurrent urinary tract infections (UTIs) that did not respond to antibiotic treatment. C considered that A's bladder cancer may have been identified earlier, and that their death avoided, had the practice referred them for investigation much sooner.

The practice's position was that A had a long history of intermittent UTIs, which were usually treated with antibiotics. At one point, all of A's urine samples showed pus cells but a normal range of red cells, which was suggestive of simple UTIs. The early signs of bladder cancer such as blood in the urine were not apparent in A's case until a relatively late stage. The practice considered that abnormalities in A's blood results (increased platelet and white cell count) were caused by A's unrelated medical conditions.

We took independent advice from a general practitioner adviser. We noted that patients over a certain age with recurrent or persistent UTIs (i.e. three episodes in 12 months) associated with haematuria (blood in the urine) should be referred for urgent investigation in accordance with national guidelines. In A's case, they had attended the practice three times in four months with recurrent UTIs and haematuria found on dipstick testing. At this point, we found that A should have been referred on an urgent basis in line with the guidance but that the practice did not do so for a further ten months. We found that the practice had failed to identify that A's blood results showed signs of recognised malignancy and that they had repeatedly failed to record A's clinical history and review the results of investigations performed. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• In view of our findings, carry out a reflective Serious Adverse Event Review (SAER) of this case which includes: a review of the failure to refer A for further investigations, including the lack of detail of their presenting symptoms and the lack of relevant clinical history in A's records; a review of the practice's result handling processes and, where issues are identified, how these are monitored and actioned by a responsible clinician; a review of the guidelines for early referral of suspected urological cancers; and a review of the failure to exclude a urine infection in relation to the care and treatment A received for a kidney infection. Information regarding a patient's care and treatment and diagnosis should be accurately recorded in their clinical records.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C's complaints related to a council-run football pitch next to their home. C reported that the noise levels from the pitch, as well as foul language by the users of the pitch were reaching unreasonable levels, particularly later in the evening before the pitch closed at 10pm, and that this was keeping their young child awake. They explained that they had provided recordings to the council to evidence this, but that the council had refused to take action to address it.

We found that the council had, in response to C's concerns, amended their letting terms and conditions to ensure that there were clear rules prohibiting unreasonable noise levels and language by renters of the pitch. However, the only steps that the council had taken to address this with users, was to send a general email about unreasonable noise to all renters of pitches they ran, warning that leases may be removed if terms and conditions were breached by unreasonable behaviour.

Given that C had been providing clear reports and recordings of specific times and behaviours, we considered it was unreasonable for the council not to take any steps to raise these issues with the specific users responsible. We also considered that the council had failed to provide sufficient explanations to C of the kind of evidence that they would consider and how they would investigate their concerns.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Explain to C what they need to do to report and evidence unreasonable use of the pitches going forward.

What we said should change to put things right in future:

• When receiving evidence of misuse of council facilities, the council should take appropriate action to ensure the users responsible abide by the letting terms and conditions.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C is an advocate for A who is a parent of child B. C complained to the Comhairle about the management of B's schooling, in particular the management of various periods of exclusion due to B's behaviours. C complained that there were occasions where B was not permitted to participate fully in their education alongside their peers and that these should have been considered as formal exclusions. The Comhairle said that there were only two periods of time that B was formally excluded and that on other occasions B was cared for in the Extended Learning Resource (ELR) unit.

In response to our investigation, the Comhairle provided evidence of B's attendance and their Included, Engaged and Involved Guideline (2013) which is the policy for managing periods of exclusion. The evidence confirmed that there were occasions B was not educated alongside their classmates but did receive specialist provision elsewhere and in accordance with the policy, these periods were not regarded as formal exclusions. We also found that during the periods where B was formally excluded, the school followed the guidelines correctly. However, there were occasions where A was requested to take B home from school early and this was contrary to the policy. The Comhairle acknowledged this and offered to formally apologise to A. We upheld the complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to follow their policy when B was sent home early from school. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C became kinship carers of A and B. C complained that the council had decided that they were not entitled to a kinship care allowance relevant to a period of nearly two years (in respect of both A and B). C said that they approached the council about kinship support and an allowance but this was not responded to appropriately at the time (including a lack of record-keeping by the council). C was of the view that if they had been given appropriate information in at the beginning, they and A and B would have been awarded what they were entitled to.

We considered the relevant legislation and guidance and took independent advice from a social work adviser. We found that C was not provided with information and advice about eligibility for a kinship care allowance and Kinship Care Orders. We also found that there was an unreasonable failure to maintain case records regarding C and A and B's involvement with social work.

We upheld C's complaint and made recommendations to the council, which, as far as possible, aim to put C back in the position that they would have been in had the failings not occurred.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not providing them with information and advice about eligibility for a kinship care allowance and Kinship Care Orders. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Complete an assessment, in line with relevant guidance, in respect of C's care of A and B. As far as possible, consideration should be given to the circumstances of the household when the assessments would have originally taken place (not just the current circumstances). If, following the assessments, the council is satisfied of A's and B's eligibility, consideration should be given to making a backdated ex gratia payment equivalent to the amount of kinship care allowance that C would have received had they been appropriately informed about the need to obtain a kinship care order.

What we said should change to put things right in future:

• Information and advice should be provided to kinship carers about eligibility for a kinship care allowance and Kinship Care Orders in accordance with the relevant legislation and guidance.
• Written case records should be appropriately maintained and retained.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.